Abstract

Background

As an illustrative example of COVID-19 pandemic community-based participatory research (CBPR), we describe a community-academic partnership to prioritize future research most important to people experiencing high occupational exposure to COVID-19 鈥� food service workers. Food service workers face key challenges surrounding (1) health and safety precautions, (2) stress and mental health, and (3) the long-term pandemic impact.

Method

Using CBPR methodologies, academic scientists partnered with community stakeholders to develop the research aims, methods, and measures, and interpret and disseminate results. We conducted a survey, three focus groups, and a rapid qualitative assessment to understand the three areas of concern and prioritize future research.

Results

The survey showed that food service employers mainly supported basic droplet protections (soap, hand sanitizer, gloves), rather than comprehensive airborne protections (high-quality masks, air quality monitoring, air cleaning). Food service workers faced challenging decisions surrounding isolation, quarantine, testing, masking, vaccines, and in-home transmission, described anxiety, depression, and substance use as top mental health concerns, and described long-term physical and financial concerns. Focus groups provided qualitative examples of concerns experienced by food service workers and narrowed topic prioritization. The rapid qualitative assessment identified key needs and opportunities, with help reducing in-home COVID-19 transmission identified as a top priority. COVID-19 mitigation scientists offered recommendations for reducing in-home transmission.

Conclusions

The COVID-19 pandemic has forced food service workers to experience complex decisions about health and safety, stress and mental health concerns, and longer-term concerns. Challenging health decisions included attempting to avoid an airborne infectious illness when employers were mainly only concerned with droplet precautions and trying to decide protocols for testing and isolation without clear guidance, free tests, or paid sick leave. Key mental health concerns were anxiety, depression, and substance use. Longer-term challenges included Long COVID, lack of mental healthcare access, and financial instability. Food service workers suggest the need for more research aimed at reducing in-home COVID-19 transmission and supporting long-term mental health, physical health, and financial concerns. This research provides an illustrative example of how to cultivate community-based partnerships to respond to immediate and critical issues affecting populations most burdened by public health crises.

Food service workers fulfill the essential societal function of ensuring access to food. The work spans multiple settings and occupations, including grocery store workers, restaurant workers, food deliverers, and more [1]. On the frontlines of the pandemic, they have frequent interactions in close proximity to densely packed groups of people, and often without rigorous health and safety protocols. Consequently, food service workers have experienced greater viral exposure, been more likely to get COVID-19 infections and reinfections, been more likely to have adverse COVID-19 outcomes, and have had some of the highest COVID-19 death rates of any occupational group [1,2,3,4,5,6,7,8,9,10,11]. Food service workers were among those at greatest risk at the pandemic onset, often lost jobs and health insurance during closures and reduced hours, were often among the last eligible for vaccines, and were among the first at risk of infection and reinfection when precautions were discontinued [1, 11,12,13,14,15,16,17,18]. These concerns remain ongoing today (September 15, 2023), as U.S. national wastewater data indicate that levels are higher than during 64% of pandemic days, 1.8% of the population is actively infectious, and 843,000 Americans are getting COVID-19 each day [19, 20]. The stress of the pandemic has been hard for many [21, 22], especially food service workers [11, 12, 23,24,25,26,27,28]. Overall, food service workers and their families have faced considerable challenges related to (1) COVID-19 health and safety, (2) stress and mental health, and (3) the long-term effects of the COVID-19 pandemic. These three challenges have been particularly difficult in the culinary city of New Orleans. Specifically, New Orleans is a racially, culturally, and socioeconomically diverse city that relies on tourism and dining as major sectors of the economy and had the highest mortality rate per capita of any major U.S. city at the pandemic onset, slightly higher than New York City [29]. As an illustrative example of COVID-19 pandemic community-based participatory research (CBPR), the current investigation was designed to better understand these three domains of pandemic concerns among food service workers in New Orleans.

The current research involved developing a community-academic partnership with local food service workers and their allies and colleagues 鈥� collectively termed the 鈥渟takeholder鈥� community 鈥� from August 2021 through February 2023. We used a combination of surveys, focus groups, and qualitative methods to identify the key pandemic concerns faced by food service workers. This multimethod, iterative approach allowed us to triangulate with an increasing focus on the key issues faced by the food service worker community. The research was designed to document concerns during the course of the pandemic, set priorities for research, programs, and policy, and inform a long-term path forward for a sustainable partnership.

Method

Overview

This research involved a collaborative partnership among academic scientists and community stakeholders in New Orleans (food service workers, allies, and colleagues) and was designed to reveal the key pandemic concerns faced by food service workers. The academic team directly engaged stakeholders who were active on the study team. The research centered on conducting a survey of the stakeholder population, focus groups, and a qualitative assessment. Study procedures were reviewed and approved by the Tulane University Institutional Review Board (IRB # 2021鈥夆垝鈥�910).

Project timeline

This report closely documents the timeline of study procedures because the pandemic has been marked by uncertainty (which affects planning) and volatility with respect to case rates, mitigation approaches, and scientific understanding (which affect the concerns of the day). The academic team partnered with food service workers to develop the proposal from December 2020 through April 2021, submitting a funding proposal in May 2021 for rapid review. The proposal was revised lightly in July 2021 based on the funder鈥檚 feedback, funded in August 2021, and launched in September 2021 while much of the team was evacuated out of town for up to a month due to Hurricane Ida and an extended power outage. The project ran through February 2023, with specific dates noted for each study activity.

Stakeholder engagement on the study team

Stakeholders contributed comprehensively to the project. Scientists and community stakeholder representatives oversaw the research as a part of a scientific advisory board, which formed in September-October 2021 and included individuals who helped submit the proposal and additional community stakeholders identified through word of mouth, social media, and listservs. Community stakeholder engagement and input guided the development of the original project proposal that was funded and supported the research, assisted with IRB, project materials, and project design, attended research team meetings, contributed to presentations, guided interpretation of the data, helped draft documents and the current manuscript, engaged in strategic planning surrounding the long-term partnership, and disseminated information to the stakeholder community. Budget planning and time commitments were discussed with each stakeholder, who provided a letter of support to align expectations, ensure equity and transparency, and ensure fair compensation. Each stakeholder was compensated for their involvement on the scientific advisory board.

The project involved academic scientists and four types of stakeholders. Academic scientists had experience in psychology, public health, epidemiology, medicine, business, and CBPR methods. The primary stakeholder group was comprised of local food service workers, which is the immediate population of interest, directly impacted by the identified problems, and most capable of informing potential solutions. The secondary group of stakeholders was family members of food service workers, who have been indirectly impacted. Next, we included people with more ancillary knowledge of issues affecting food service workers, including food business executives (expertise in understanding employer constraints) and locals knowledgeable of schools (since many food service workers have children and noted during the grant-writing phase that school COVID-19 protocols can impact the health, safety, and ability to work for others in the family). Representatives of the stakeholder community joined the academic scientists as equal members of the scientific advisory board. Stakeholders on the scientific advisory board had the option but were not required to contribute as research participants in the project survey, focus groups, or rapid qualitative assessment. The composition of the scientific advisory board was fluid as members moved out of state or took on larger or smaller roles, with typically five academic scientists and five stakeholders highly involved.

Survey of the stakeholder population

Survey respondents were people currently working in a New Orleans food service occupation who completed a survey about their experience dealing with the pandemic. Study data were collected at the tail end of the Omicron BA.1 surge, from February 2022 through April 2022. Participants were recruited via word of mouth, email, and social media, and the research team confirmed occupational eligibility through a conversation about their work. They completed the consent form and survey online via Qualtrics. The survey assessed health and safety precautions, the stress and mental health effects of the COVID-19 pandemic, long-term health and social impact of COVID-19, and other pandemic-related concerns. Questions asked about their workplace, their self-reported experience, and their perceptions of the issues faced by other locals in the food service community. We included perceptions of the local food service community because (a) respondents may report more accurately on controversial topics (e.g., Long COVID impairment, substance use) when focused on relevant others instead of themselves, and (b) averages of multiple informants often provide a reasonably valid picture of a particular context, even when specific individuals may overestimate or underestimate community concerns. Participants were compensated with a $25 gift card for completing the survey. Descriptive analyses (means, standard deviations, frequencies) were conducted in SPSS 27.

Focus groups

The research team conducted three sets of focus groups from April 2022 to October 2022, a period marked by low pandemic precautions and high transmission from Omicron BA.2 (dominant from April-June) and BA.5 (dominant from July-October). Each focus group corresponded to one of the three identified problem areas affecting frontline essential food service workers and their families: COVID-19 health and safety precautions (April 2022), stress and mental health (June 2022), and the long-term impact of the pandemic (October 2022). We sought to involve stakeholders most committed to each meeting鈥檚 specific problem area, based on prior informal discussions between scientists and community members, often ascertained as community members reached out to ask about the project, attended community presentations, or asked about the survey. Focus group meetings lasted approximately one hour each and occurred at times convenient for stakeholders. The focus group meetings were facilitated by the lead investigator (MH) and held remotely via Zoom to ensure safety during the pandemic. Participants were compensated with a $100 gift card for participating in a focus group.

The first focus group topic focused on health and safety issues surrounding vaccination and other COVID-related precautions. Due to high interest in the first focus group, we split participants into two subgroups held separately, one in the evening, and one the next morning. Attendees selected which time to attend. The groups discussed difficulties (e.g., biggest challenges, difficult decision-making), successes (e.g., things that have gone well), and areas for future improvement (e.g., needed resources) in relation to COVID-19 health and safety precautions.

The second round of focus groups focused on stress and mental health during the COVID-19 pandemic. The meeting discussed challenges (e.g., negative feelings, stressors), successes (e.g., financial support, local initiatives, empathy and understanding), and areas for future improvement (e.g., access to mental healthcare, support groups) in relation to stress and mental well-being.

The third round of focus groups discussed perceptions, thoughts, or opinions on long-term impacts of the COVID-19 pandemic on food service workers. The meeting discussed long-term impacts on health (e.g., long COVID-19 symptoms, long-term health needs), financial status and career goals (e.g., challenges, goals, resources, and strategies), and other items (e.g., inflation, mistreatment, attitudes).

Each meeting was audio-recorded and transcribed for the purpose of analysis. Two members of the research team coded transcripts in Atlas.ti using thematic analysis, an iterative process that allows researchers to identify and refine themes within the data. Codes, coded transcripts, and emerging themes were reviewed by three members of the research team to ensure preliminary agreement. When there were disagreements, concepts were discussed until consensus was reached. All co-authors reviewed themes for acceptability.

Rapid qualitative assessment

In the funding proposal, we indicated that we would end the project by conducting a rapid qualitative assessment designed to obtain quick, open-ended feedback on a key topic identified as a future research priority based on the earlier survey, focus groups, and informal community feedback. The focus and methodologic details were intentionally vague in the funding proposal, as this stage was designed to be driven by prior feedback and experience and the ongoing state of the pandemic. The assessment was conducted from December 2022 to January 2023 to maximally inform the next steps of planning for future research.

Based on the collective feedback received throughout the course of the project, stakeholders and academic scientists agreed that the assessment should focus on understanding and supporting food service workers in grappling with a key issue lingering in late 2022: reducing the in-home spread of COVID-19 when a family member or housemate tests positive. Collective feedback to that point was that public health mitigation was low but that food service workers still cared deeply about reducing in-home transmission. The rapid qualitative assessment asked participants to describe their occupation or expertise and answer five open-ended questions online via Qualtrics, taking 10鈥�20听min total. We approached this issue bidirectionally. First, food service workers completed a rapid qualitative assessment about their experiences attempting to avoid in-home transmission, challenges, and areas of uncertainty. Specifically, they were asked to describe their biggest challenges surrounding reducing in-home transmission, tips and challenges using key COVID-19 mitigation approaches, tips and challenges communicating with others about the rationale for behavior changes, advice requested from COVID-19 mitigation professionals, and other comments. Second, a national panel of COVID-19 mitigation professionals who were colleagues of the corresponding author completed a parallel assessment advising on best practices for reducing in-home transmission and handling social interactions. They were provided a scenario of a working-class two-parent family with children ages 3, 5, and 7, and asked what they would recommend the family do if the 3-year-old tested positive. Follow-up questions varied the ages of the children to make them older (i.e., 13, 15, and 17), asked about recommendations for single-parent families, asked about recommendations for higher-income families, and any other comments.

Results

Survey of new orleans food service workers

Sociodemographics

Participants (N鈥�=鈥�23) ranged from 19 to 58 years old (Mean [SD]鈥�=鈥�35.35 [9.60]), with 52.2% female, 56.5% non-Latino/a white, 47.8% having a college degree, 39.1% married or living with a partner, 60.9% employed full-time in the food services industry as opposed to part-time. They worked in their current job for an average of 3.10 (SD鈥�=鈥�3.53) years and had been in the food service industry for an average of 7.28 (SD鈥�=鈥�3.28) years, with nearly half (47.8%) having over 10 years of experience working in a food service-related occupation.

Workplace description

Participants experienced widespread concerns related to health and safety precautions, stress and mental health, and the long-term impact of the COVID-19 pandemic (Tables听1, 2 and 3). Regarding employer-provided health and safety benefits (Table听1), respondents indicated that most employers took droplet and surface (fomite) precautions (free soap, hand sanitizer, and gloves, 56.5-73.9%) but did not take airborne precautions (CO₂ monitoring, HEPA filters, free high-quality masks, 4.3-21.7%). Although employers encouraged food service workers to stay home when sick (69.6%), few provided paid sick leave (21.7%) nor comprehensive health benefits (mental health, vision, dental, and health insurance, 8.7-39.1%). Job satisfaction was modest (3.66 on a 1鈥�5 scale, Table听2), and they estimated that many co-workers were dealing with financial concerns, a history of a COVID-19 infection, mental health concerns, and Long COVID (8.0-71.3%, Table听3).

Table 1 Food Service Worker Survey on Workplace Health and Safety Benefits, Reported Immediately Following the BA.1 Omicron Surge

Table 2 Food Service Worker Survey on Self-Reported Experience with the Pandemic, Reported Immediately Following the BA.1 Omicron Surge

Table 3 Food Service Worker Survey on the Local Food Service Worker Community, Reported Immediately Following the BA.1 Omicron Surge

Health decision-making

Overall, respondents noted that the local food service worker community faced considerable burdens related to health decision making (Table听3). Respondents indicated that the food service worker community struggled with what to do if they or a family member were sick or tested positive (73.9-87.0%), how to deal with customers regarding precautions (69.6-82.6%), testing concerns (34.8-65.2%), masking (30.4-69.6%), vaccinations (60鈥夆垝鈥�9-82.6%), and reducing transmission risk within one鈥檚 family (30.4-82.6%). As shown in Table听2, food services workers were highly vaccinated (95.7%, 87.0% receiving a dose in the past 6 months). Participants鈥� households were highly vaccinated. They viewed vaccines as safe, would recommend them to others, and were 鈥渧ery鈥� concerned about COVID-19 before vaccines were available but less so after (73.9% vs. 8.7%).

Mental health

Participants described the pandemic as negatively affecting mental health, that mental health was stigmatized, and that mental healthcare access was very difficult. Nearly half of participants (47.8%) indicated that the pandemic had affected their mental health (Table听2). Ratings of personal coping, stress, life satisfaction, meaning and purpose, social satisfaction, and sleep quality were highly variable (Table听2). As shown in Table听3, respondents estimated that the most pressing mental health concerns among local food service workers were anxiety (95.7%), depression (78.3%), and substance use (69.6%). As well, 17.4% of respondents identified suicidal ideation as the most pressing concern among local food service workers, and another 17.4% reported violence or abuse as a pressing concern. The leading primary sources of anxiety were the uncertainty of when things would return to normal (82.6%), financial concerns (up to 73.9%), and COVID-19 infections (73.9%).

Long-term impact

Food service workers were variable in terms of the key areas where they observed long-term consequences of the COVID-19 pandemic (Tables听2 and 3). As shown in Table听2, respondents indicated that key long-term concerns among local food service workers were underemployment/unemployment, mental health, business closures, pay cuts, insurance loss, and Long COVID (means of 2.83 to 3.22 on a 1鈥�4 scale). Within respondents鈥� own families (Table听2), the most common financial concerns of food service workers and their families included hour cuts, pay cuts, postponed travel, short-term unemployment, and postponed medical and dental care (39.1-47.8%). Other standout concerns include extra medical bills surpassing $500 (30.4%), extra alcohol expenses (26.1%), long-term unemployment鈥�>鈥�6 months (21.7%), late rent/mortgage payments (21.7%), difficulty paying utilities (21.7%), home eviction (8.7%), and car repossession (8.7%). When participants were asked whether they were personally aware of a local food service worker experiencing Long COVID symptoms, top reported concerns were fatigue, anxiety, depression, loss of taste, and difficulty sleeping (47.8鈥�65.2% of participants were aware of someone experiencing such symptoms, Table听3).

Focus groups

The first focus group (N鈥�=鈥�11) was split into two subgroup meetings (n of 4 and 7) and focused on COVID-19 health and safety precautions (Table听4). Key challenges included conflicts with customers, limited business due to closures and then reduced demand, personal challenges surrounding health decision making, and a lack of workplace support. Key successes included city safety precautions, workplace safety precautions, and some of the available resources, such as unemployment benefits and community meal programs. Areas for future improvement were maintaining mandates, financial support, the dissemination of information, and improvements in benefits.

Table 4 Summary of Themes in Focus Group 1 on COVID-19 Health Safety and Precautions

The second focus group (N鈥�=鈥�9) focused on stress and mental health concerns resulting from the pandemic (Table听5). Key challenges included emotional distress (guilt, hopelessness, and uncertainty), specific stressors especially related to their families (not being able to see family, children being sick), and mental health difficulties (substance use, anxiety, and depression). Key successes included financial support that 鈥� although limited 鈥� reduced stress, and social support from friends and family. The key area of need for improvement was access to mental healthcare.

Table 5 Summary of Themes in Focus Group 2 on Stress and Mental Health

The third focus group (N鈥�=鈥�6) focused on the long-term impact of the COVID-19 pandemic (Table听6). The key issues related to health impacts were Long COVID, reinfections, and the role of employer support. Key issues related to financial and career impacts included repercussions of the larger economy, changing career plans, extra income sources, and changes in the employer鈥檚 financial strategy.

Table 6 Summary of Themes in Focus Group 3 on the Long-Term Impact of COVID-19

Rapid qualitative assessment

Food service workers (N鈥�=鈥�7) completed a rapid qualitative assessment focused on key challenges surrounding themselves or someone in their home testing positive, and COVID-19 mitigation professionals (N鈥�=鈥�8) provided insights into various mitigation strategies aimed at reducing the likelihood of transmission (Table听7). For food service workers, key challenges included reducing in-home COVID-19 transmission, navigating work, school, and other social interactions, using different approaches to limit the spread of COVID-19, and making informed decisions about appropriate COVID-19 precautions. Specifically, food service workers expressed concerns about balancing the financial risks of prolonged isolation with safety, sought guidance on reducing transmission both at home and in the workplace, and managing the stress and mental health challenges associated with the pandemic. The workers emphasized the need for clear guidelines and support systems to navigate these complex situations, particularly in decision-making about when to drop precautions and return to work without compromising safety.

Table 7 Summary of the Rapid Qualitative Assessment on COVID-19 Mitigation: Perspectives from Food Service Workers and COVID-19 Mitigation Professionals

COVID-19 mitigation professionals recommended a multi-layered approach to reducing in-home transmission that included using high-quality masks (e.g., N95), improving ventilation by bringing in outdoor air where feasible, enhancing air cleaning through HEPA filters and do-it-yourself (DIY) homemade air cleaners, such as Corsi-Rosenthal boxes [30,31,32,33,34,35]. Corsi-Rosenthal Boxes 鈥� named for the engineers that designed them 鈥� are like HEPA filters but are lower cost and can be built with supplies at most hardware stores, such as a box fan, HVAC filters, and duct tape. The professionals also stressed the importance of testing, including PCR or rapid tests, to ensure accurate isolation for positive individuals. They suggested reaching out to friends, family, and local communities for additional support and exploring remote job opportunities in case of financial difficulties.

Discussion

This research has documented the pandemic-related concerns of food service workers surrounding health and safety, stress and mental health, and the long-term effects of the COVID-19 pandemic. The research also provided an illustrative example of CBPR by demonstrating success in developing an academic-community partnership amid crisis. Food service workers described their experience living through the pandemic from its onset through the close of the study in February 2023, providing reasonably comprehensive coverage of the first 3 years of the pandemic from the perspective of New Orleans food service workers. Figure听1 summarizes the key findings and next steps for research, programs, and policy. Key findings were that food service workers (1) were provided workplace COVID-19 droplet-based protections that were insufficient against a highly-infectious airborne illness, (2) had to make difficult decisions about health and safety with limited definitive public health guidance and structural supports, (3) faced considerable stressors and mental health concerns, especially depression, anxiety, and substance use, with limited counseling support, (4) continue to experience long-term health, mental health, and financial impacts, and (5) want more support to prevent in-home COVID-19 transmission and gain more support around health, mental health, and financial well-being in the food service industry. Our multi-method, phased research process of moving from a survey to focus groups to a rapid qualitative assessment offered a combination of big-picture empirical evidence mixed with real-world examples and allowed us to increasingly shift from identifying problems toward targeting priorities for future solutions. Findings have implications for future research, programs, and policy aimed at mitigating the lingering impact of the COVID-19 pandemic, future pandemics and health crises, and other airborne respiratory illnesses among individuals at high risk of occupational exposure.

Fig. 1

Summary of a CBPR Study Engaging the Food Service Worker Stakeholder Community and Scientists to Respond to Key COVID-19 Pandemic Concerns. The outside arrows show that community members and scientists were engaged in iterative feedback processes that encompassed all aspects of the project, from the proposal to methodology to findings to dissemination. The collaboratively designed funding proposal focused on three key issues (health and safety, stress and mental health, and long-term impact), which were studied using a combination of methods, a survey (S), three focus groups (FG), and a rapid qualitative assessment (RQA). Findings identified key concerns within each of the three topic areas. The project informed future research priorities, outreach activities, and plans for ongoing and future programs and policy initiatives

Although prior studies have documented some of the pandemic burdens faced by food service workers, this research highlighted the root of those burdens: food service workers were often offered low-level droplet mitigation rather than high-level airborne mitigation, creating high-exposure risk environments that led to a disproportionate burden from the pandemic. Adhering to common public health guidance, employers provided precautions mainly against basic droplet transmission (e.g., soap, hand sanitizer, gloves, low-quality masks), rather than airborne transmission (e.g., high-quality masks, ventilation, filtration via air cleaners, and air-quality monitoring). However, COVID-19 is now widely accepted to transit predominantly through the airborne route [36,37,38,39,40], with White House COVID-19 Response Coordinator, Ashish Jha, MD, referring to COVID-19 transmission as 鈥減urely airborne鈥� in October 2022 [41]. Our research is the first of which we are aware to explain the pandemic-related burdens of food service work in terms of a lack of airborne COVID-19 mitigation.

This discrepancy between droplet precautions and airborne transmission helps explain prior findings that food services workers have experienced worse COVID-19 health outcomes than most other workers [1,2,3,4,5,6,7,8,9,10,11]. Like COVID-19, many illnesses transmit through the indoor air people breathe [40]. Recognizing the dangers of airborne illness transmission, the highest-ranking building engineering organization with 50,000 members in 130 countries, called the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), published 2023 indoor air cleaning standards for the control of infectious aerosols [42]. The new standards indicate that restaurants and similar establishments should clean the air approximately 28鈥�40 times per hour, depending on occupancy level (more precisely, 40 cubic feet per minute per person [cfm/person] or 20听L per second per person [l/s/person]) to reduce airborne illness transmission, approximately double the historic standard of 15 air changes per hour in U.S. operating rooms. To put in context, many restaurants, bars, and similar establishments clean the air 0.8 times per hour [43], 35鈥�50 times lower than the current ASHRAE air cleaning standards. As the engineer Devabhaktuni Srikrishna frequently notes, even fish get 4鈥�6 full water exchanges per hour in properly running fish tanks [44]. Essentially, food service venues are among the highest-risk settings and have the lowest mitigation. The ASHRAE standards are a firm indication of the occupational hazards of food service work. More research is needed to improve health and safety for food service workers, particularly during airborne illness crises.

Similarly, food service workers experienced a gap between what was offered and what was needed with regard to other COVID-19 health and safety concerns, stress and mental health, and the long-term impact of the COVID-19 pandemic. Regarding health and safety, employers encouraged food service workers to stay home when sick, but did not always provide free tests, guidance on testing, paid sick leave, or even health insurance. In general, food service workers faced challenging decisions surrounding vaccinations/boosters, masking, testing, isolation, quarantine, and how to reduce in-home transmission. Nonetheless, they often made wise, cautious decisions, with the vast majority having utilized vaccines, masks, testing, and routinized safety protocols. Additionally, participants indicated key concerns surrounding stress and mental health, especially related to anxiety, depression, and substance use and called for more mental health support in the community. Food service workers also indicated that they were experiencing long-term consequences of the COVID-19 pandemic in terms of mental health, Long COVID, and financial strain. Overall, food service workers were under-supported, often provided the 鈥榳rong鈥� tools or no tools at all, with broad impacts on health and mental health in the short- and long-term.

This research had strengths and limitations. The key strengths were stakeholder-engagement, community-centeredness, the use of multiple methods of assessment to triangulate priorities and capture variation over the course of the pandemic, and the innovation of responding to the pandemic in real-time, submitting a funding proposal in May 2021, when many thought the pandemic was 鈥渙ver,鈥� instead of in a low point before viral evolution that produced the Delta variant, Omicron variant, and many Omicron subvariants. Limitations include the small sample sizes that are common when gathering detailed and sensitive information, the subjectivity of participants鈥� perspectives, and the dynamic nature of the pandemic, which means that findings at one point in time may be less relevant at a future timepoint.

Future research should focus on evaluating interventions to support the top concerns identified by stakeholders. In a world where most mitigation has been dropped, stakeholders universally cared about avoiding spreading COVID-19 within the home. At this point in time (September 2023), COVID-19 continues to transmit at a high rate, with over 800,000 American infected daily [19, 20]. In-home transmission has remained a concern throughout the pandemic [45,46,47]. Mitigation professionals identified actionable interventions to reduce in-home spread when someone has illness symptoms at home, including opening windows, using fans strategically, using DIY air cleaners called Corsi-Rosenthal Boxes, wearing high-quality masks, and testing to end isolation periods. Although these interventions have underlying efficacy data [30,31,32,33,34,35,36,37,38,39,40, 48,49,50], the question remains whether these specific interventions would work in the context of a comparative effectiveness trial to reduce in-home transmission under community-based circumstances with less scientific control. Such studies would be of high value for people working in settings with high transmission risk [9, 10], as well as for vulnerable populations like people with cancer or who are immunocompromised [34, 35]. Future studies should also examine interventions for reducing mental health concerns, like anxiety, depression, and substance use, as well as the financial strain exacerbated by the pandemic. This program of research would help reduce the pandemic impact experienced by people working in settings with high risk of exposure.

Although our report focuses on the development of a community-based partnership and the findings from such research, it should be noted that an important goal of CBPR is to establish long-term collaborations to drive the development of programs and policies to help the community. During the course of this partnership, we developed social media accounts, a website, and a listserv, held three public community meetings that were available live online, and wrote three brief handbooks with advice on conducting CBPR during public health crises [51,52,53]. These were collaborative efforts involving iterative input from scientists and the community. We have developed a strategic plan for the next three years. Moreover, we have already begun to develop programs and support improved policy initiatives for the food service worker community and others at high-exposure risk or with medical vulnerabilities [34, 35, 48, 54,55,56].

A few recent and ongoing examples may help illustrate how this type of project can have a broader impact on the community. Foremost, during the BA.1 Omicron surge, we led the first known research study [48] that involved distributing high-quality N95 masks to the community, launching our program before the New Orleans city and federal initiatives. We disseminated the work widely on social media, helping communities across the U.S., Canada, Europe, and Australia to develop 鈥渕ask blocs鈥� to provide free masks to those working in high-exposure settings or with medical vulnerabilities. A New Orleans mask bloc called Fight COVID NOLA 鈥� building upon but independent of our group 鈥� has now given away thousands of masks, often targeting support for the food service community. Second, we recently launched a COVID-19 dashboard [19] that uses national wastewater data to model current U.S. case rates, the percentage of the population who are actively infectious, the number of new daily Long COVID cases, and forecast future case rates. It has been viewed鈥�>鈥�3听million times within the first 6 weeks of launch and will help people in high-risk settings to advocate for stronger mitigation. Third, in late June 2023, ASHRAE released the final draft of its standards for the control of infectious aerosols [42]. The standards use engineering terminology. We are translating that information into lay summaries and sharing through social media, recent [34, 35] and future publications, explainers, graphics, pro bono consulting with individuals and collective bargaining units, and more. As a part of our strategic plan, we will spend the next several years supporting improved air quality in restaurants, vaccine booster outreach, testing, and comprehensive interventions to reduce in-home transmission. These programs and policies will benefit the local food service worker community, food service workers in other communities, and society more broadly.

Conclusions

In closing, this research provides an illustrative example of how to partner with stakeholders to conduct CBPR during public health crises and prioritize future research topics, programs, and policies. The top priority for future pandemic research among food service workers was to reduce in-home transmission when someone in the family tests positive for COVID-19. Moreover, the knowledge, skills, and collaborations developed through this research are expected to inform programs and policies to help food service workers and other high-exposure and vulnerable people stay safer from COVID-19.